Introduction: Prostate cancer is a major public health concern and a leading cause of cancer-related morbidity and mortality. This study aims to compare positivity rates for clinically significant prostate cancer (csPCa) detected through three different transperineal prostate biopsy (TPPB) methods: Under general anesthesia (GA) with a brachytherapy grid and cognitive MRI fusion (CF), Freehand under local anesthesia (LA) with CF, and under GA with software-based MRI fusion (SF).Current data on this topic are limited to small series, making this multicenter study particularly relevant. Methods: A total of 1,272 patients from Australia, New Zealand, and Switzerland were included in this retrospective review. Collected demographic and clinical data included PSA levels, PSA density (PSAD), MRI report (PiRADS score), BMI, and histology results. Statistical analyses were conducted to assess differences in csPCa positivity rates among the three methods. Results: The study included 259 Australian patients who underwent TPPB with CF under GA, 505 New Zealand patients who had freehand TPPB with CF under LA and 508 Swiss patients who had TPPB under GA with SF. For patients with PiRADS 3 lesions, csPCa positivity rates were 23% (Australia), 20% (New Zealand), and 12% (Switzerland); for PiRADS 4, rates were 49%, 67%, and 46%, respectively; and for PiRADS 5, rates were 80%, 85%, and 76%, p value < 0.001. Notably, there were significant differences (p < 0.001) in age, PSA levels, and PSAD among the centers, which may have contributed to these variations in csPCa detection rates between methods. Conclusion: Our findings suggest that freehand biopsies under LA with CF demonstrate higher csPCa positivity rates compared to the other methods.